چکیده انگلیسی

Borderline personality disorder (BPD) is considered one of the most expensive mental disorders in terms of direct and indirect costs. The aim of this study was to carry out a cost–offset estimation of disorder-specific psychotherapy for BPD at the population level. The study investigated whether the possible financial benefits of dialectical behavior therapy outweigh the therapy costs, assuming a currently running, ideal health system, and whether the estimated cost–benefit relationships change depending upon the number of patients willing to be treated. A formula was elaborated that allows the user to calculate cost–benefit relationships for various conservative or progressive scenarios, with different stages of individuals' willingness to be treated (10%–90%). The possible costs and benefits of BPD-related treatment were evaluated using a 12-month, prevalence-based approach. The annual costs for untreated BPD were 8.69 billion EUR annually. The cost–benefit relationship for the treatment remained constant at 1.52 for all scenarios, implying that for each EUR invested, 1.52 EUR can be gained within one year, independent of the willingness to be treated. Additional intangible benefits were calculated with the aid of Quality-Adjusted Life Years. Findings suggest that BPD-related treatment might well be efficient at the population level.

مقدمه انگلیسی

Borderline personality disorder (BPD) is a life-threatening mental disorder that is strongly characterized by lifetime rates of approximately 70% for acts of self-injury, 80% for suicide attempts, and 10% for suicide (Black et al., 2004, Linehan and Heard, 1999 and Paris, 2002). The prevalence of BPD in the general population ranges from 0.5 to 1.4% (Samuels et al., 2002, Torgersen et al., 2001, Coid et al., 2006 and Lenzenweger et al., 2007). Yet the proportion of patients with a diagnosis of BPD in psychiatric care ranges between about 15% of outpatients and 30% of inpatients (Alnæs and Torgersen, 1988, Zimmerman and Mattia, 1999 and Loranger et al., 1994). Individuals with BPD require more treatment services than patients with other disorders (Bender et al., 2001 and Zanarini et al., 2001). Therefore, BPD is considered one of the most expensive mental disorders (Soeteman et al., 2008 and Van Asselt et al., 2007), causing high direct and indirect costs. Direct costs include all treatment costs that are directly associated with BPD (e.g., hospital days or emergency department visits). Indirect costs cover all costs that occur secondary to the disorder (e.g., production losses and sickness benefit payments due to days absent; e.g., Brent, 2008 and Margraf, 2009). Additional losses can be expected in terms of intangible values, which refer to the reduced quality of life and suffering caused by BPD as well as “years lost” due to mortality.
To the best of our knowledge, so far only three studies have been conducted that investigated the issues of costs and benefits of therapy for BPD. (1) Using a prevalence-based, bottom-up approach, societal costs of BPD in the Dutch population were calculated, resulting in an estimation of costs at around 17,000 EUR per patient each year (Van Asselt et al., 2007). The overall annual costs covered healthcare, medication, informal care, productivity losses, and out-of-pocket expenses. In this study, one third of the people affected by BPD were fully disabled and those who were employed reported that they had been absent from their jobs for more than five weeks per year. (2) In another study on this sample, the cost-effectiveness of borderline-specific treatment was calculated (Van Asselt et al., 2008). Comparing schema-focused therapy (SFT) vs. transference-focused psychotherapy (TFP) for outpatients with BPD, the investment for SFT was lower (37,826 EUR for SFT vs. 46,795 EUR for TFP) while the recovery rate was higher (52% for SFT vs. 29% for TFP), implying that SFT is more efficient than TFP. The analyses considered a wide range of direct and indirect costs and intangible losses, but since the analyses considered cost-effectiveness, they were not transferred into financial values. (3) Comparing dialectical behavior therapy (DBT) vs. treatment-as-usual (TAU) for outpatients who predominantly suffered from BPD revealed that DBT was more expensive in terms of treatment costs (Priebe et al., 2012). In the additional cost-effectiveness analysis, health care outcomes related to self-injury were calculated. This analysis was not particularly specific to BPD, although most of the patients were affected by BPD. The analyses of these three studies were based on small sample sizes, ranging from 20 to 88 participants.
The aim of the present study was to carry out a population-based cost–offset estimation of psychological therapy for BPD, using data from the German health care system. The perspective is a societal one, considering the possible impact of therapy on direct and indirect costs for the health care system (hospital days, emergency department visits, sickness benefit payments), on society (unemployment, early retirement), and the economy (production losses, loss of gross value), as well as on intangible costs in the form of Quality-Adjusted Life Years (QALYs), a construct frequently used by the World Health Organization (e.g., Prüss-Üstün, Mathers, Corvalán, & Woodwair, 2003). The approach is prevalence-based and not incidence-based: Given a constant 12-month prevalence, the costs of BPD and the benefits of its treatment could be evaluated for this period. Thus, all individuals affected by BPD within one year were included in the estimation, irrespective of the duration of their illness. It was not assumed that the intervention reduced the prevalence at the population level; in other words, potentially deteriorating individuals or those newly diagnosed with BPD are already included in this prevalence. The study included the costs incurred by all patients who might be willing to undergo treatment within one year, as well as the benefits created by the patients whose symptoms improved within that one year. The individuals who were treated within the considered year were not necessarily the same individuals whose symptoms improved and who were responsible for the financial benefit within that year; i.e., running costs and running benefits were considered, but time trade-off was not. This implies the assumption of an “ideal health services system;” in other words, for each patient who might be willing to be treated, treatment can be offered promptly. The initial costs for the dissemination of the intervention were not taken into account. In contrast to some of the previous studies, which were in medias res or ex post studies, this study represents an ex ante estimation based on data provided by institutions like health insurance providers or the German pension fund. Ex ante analyses are usually carried out before a particular project is started in order to help decide whether resources should be allocated to that project, in contrast to in medias res or ex post studies, which evaluate the costs and benefits during (in medias res) or at the end (ex post) of a project. Generally, ex ante studies are less accurate than in medias res or ex post studies because the possible benefits and costs have to be estimated in advance and cannot be directly evaluated, as is possible at the end of a project ( Boardman, Greenberg, Vining, & Weimer, 2011). The aim is to present a possible method of calculating costs and benefits of the treatment of BPD ex ante, which can be performed for any treatment approach if the relevant data are available.